The top row presents the distribution of complex chronic conditions among pediatric severe sepsis hospitalizations, while the bottom row presents the distribution of costs. For example, 5436 of 23 364 hospitalizations (23.3%) occurred among children with no comorbidities, and these accounted for 7.2% of total costs ($139 million [95% CI, $132 million-$146 million]). Meanwhile, 2835 of 23 364 hospitalizations (12.1%) occurred among children with 5 or more chronic complex conditions, and these accounted for 25.6% of total hospitalization costs ($495 million [95% CI, $464 million-$526 million]).
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Carlton EF, Barbaro RP, Iwashyna TJ, Prescott HC. Cost of Pediatric Severe Sepsis Hospitalizations. JAMA Pediatr. 2019;173(10):986–987. doi:10.1001/jamapediatrics.2019.2570
In 2005, the most recent year for which nationwide estimates are available, the total costs of pediatric severe sepsis hospitalizations were estimated at $4.8 billion ($5.8 billion in 2016 dollars).1 Since then, there has been increasing attention to severe sepsis, revision of sepsis treatment guidelines, and a growing prevalence of children with medical complexity who account for the large portion of health care expenditure, hospitalization stays, and readmissions.2,3 Thus, we sought to measure the current costs of pediatric severe sepsis and understand the association of complex chronic conditions with sepsis hospitalization costs.
We studied pediatric hospitalizations (in patients 19 years or younger) in the 2016 Nationwide Readmissions Database, which includes all-payer hospitalization claims from 27 states that represent 57% of the US population. Pregnancy-associated hospitalizations were excluded. We identified severe sepsis using International Classification of Diseases, Clinical Modification, Tenth Edition (ICD-10) codes for severe sepsis or septic shock and concomitant codes for infection and acute organ dysfunction (as per the modified Angus criteria). The list of relevant ICD-10 codes was identified in a prior study, which used forward and backward mapping to Centers for Medicare & Medicaid Services’ general equivalency mappings with manual review to ensure appropriateness.4 Also, we compared 2014 with 2016 hospitalizations and confirmed that a crosswalk from the International Classification of Diseases, Ninth Edition to the ICD-10 resulted in a similar number of severe sepsis hospitalizations identified. The Nationwide Readmissions Database is a deidentified dataset, is considered exempt, and does not require institutional review board review.
We measured comorbidities using the Complex Chronic Conditions Classification.5 In subgroup analyses, we examined hospital costs by the number and type of complex chronic conditions and hospital mortality rates. Using linear regression, we measured hospitalization costs by the number of complex chronic conditions, adjusting for lengths of stay and ages. Additionally, we determined the nationwide estimated cost among newborn and nonnewborn hospitalizations. To directly compare 2005 costs with 2016 costs, we performed a sensitivity analysis and identified severe sepsis using concomitant ICD-10 codes of infection and acute organ dysfunction (per the Angus criteria).
Nationwide estimates were determined using Nationwide Readmissions Database sampling weights. We estimated total hospital costs using cost-to-charge ratios provided by the Nationwide Readmissions Database and standardizing all costs to 2016 US dollars using the Gross Domestic Product Price Index.6 Statistical analyses were performed using StataMP version 15 (StataCorp), with a 2-sided P value less than .05 set as the threshold for significance. Data analysis occurred between December 2018 and March 2019.
The estimated total nationwide cost of pediatric severe sepsis was $7.31 billion (95% CI, $4.36 billion-$10.3 billion) in 2016 in an estimated 72 288 (95% CI, 55 103-89 473) hospitalizations (Table). The median cost per hospitalization was $26 592 (95% CI $25 839-$27 346), 12 times the median cost ($2199 [95% CI, $2194-$2205]) of all-cause pediatric hospitalizations. In total, severe sepsis hospitalizations accounted for $7.3 billion of $40.3 billion (18.1%) in nationwide estimated pediatric hospitalization costs.
Children with at least 1 complex chronic condition accounted for 17 928 of 23 364 severe sepsis hospitalizations (76.7%) but $1.79 billion of $1.93 billion in costs (92.6%). Median hospitalization costs were substantially higher among children with vs without chronic complex conditions ($36 332 [interquartile range (IQR), $12 730-$110 039] vs $10 963 [IQR, $5288-$27 147]) (Figure). With each additional chronic complex condition, hospitalization costs increased by $6970 (95% CI, $6313-$7627; P < .001) after adjusting for age and length of hospitalization. Severe sepsis hospitalizations among children with neonatal complex chronic conditions were the most costly (median [IQR], $168 055 [$68 654-$316 855]), followed by transplant-associated complex chronic conditions (median [IQR], $128 425 [$35 667-$323 990]). Median costs were higher in the 1199 of 23 364 children (5.1%) who died during hospitalization compared with the 22 159 of 23 364 children (94.9%) who survived (median [IQR], $82 127 [$29 547-$248 532] vs $25 007 [$9235-$79 139]; P < .001). Newborn hospitalizations resulted in an estimated nationwide cost of $1.96 billion (95% CI, $1.3 billion-$2.6 billion) compared with $5.4 billion (95% CI, $2.9 billion-$7.75 billion) among nonnewborn infants and children. In a sensitivity analysis using prior study definitions (Angus criteria), there were an estimated 69 835 hospitalizations, costing $7.2 billion dollars—a 23% increase from the 2005 estimate ($5.8 billion; Table).
Pediatric severe sepsis hospitalizations cost more than $7 billion in 2016 and have risen nearly 25% in inflation-adjusted price since 2005 estimates. Hospitalization costs are higher among children with complex chronic conditions and those who do not survive.
This study is limited in that only half of Nationwide Readmissions Database states provide data on children younger than 1 year; however, these hospitalizations are weighted more heavily in nationwide estimates. Additionally, while modified Angus criteria have been validated in an adult population, this has yet to be performed in a pediatric populace.
Acute inpatient care of severe sepsis is associated with nearly one-fifth of hospitalization costs (ie, 18.1% of $40.3 billion) among US children. This likely underestimates total costs, because these estimates do not include posthospital costs or lost work among caregivers.
Accepted for Publication: March 27, 2019.
Corresponding Author: Erin F. Carlton, MD, Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109 (email@example.com).
Published Online: August 12, 2019. doi:10.1001/jamapediatrics.2019.2570
Author Contributions: Drs Carlton and Prescott had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Carlton, Barbaro, Prescott.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Carlton.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Carlton, Prescott.
Administrative, technical, or material support: Prescott.
Conflict of Interest Disclosures: Dr Barbaro reports serving as chair of the Extracorporeal Life Support Organization Registry. Dr Iwashyna reports grants from VA Health Services Research and Development and the National Institutes of Health during the conduct of the study. Dr Prescott reported grants from the National Institutes of Health during the conduct of the study. No other disclosures were reported.
Funding/Support: This work was supported by from the National Institutes of Health (grant K08 GM115859 [Prescott]) and Training to Advance Care Through Implementation Science in Cardiac and Lung Illnesses (TACTICAL) from the National Heart, Lung, and Blood Institute/National Institutes of Health (K12 HL138039 [Dr Barbaro]).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.